Dr. Katrin KohlMedical Officer

Centers for Disease Control and Prevention

Public Health Events and International Health Regulations

Emerging Infectious Diseases

National Center for Emerging and Zoonotic Infectious Diseases

Emerging Infectious Diseases July 2012

Based on the article Assessment of Public Health Events through

International Health Regulations, United States, 2007–2011

Katrin S. Kohl, Ray R. Arthur, Ralph O’Connor, and Jose Fernandez

What are International Health Regulations (IHR)?

The International Health Regulations (IHR) are an international legal instrument that is binding on 194 countries across the globe, including all member states of the World Health Organization (WHO). The United States is one of these member states.

IHR are intended to: help prevent the spread of disease across borders

outline the minimum requirements for functional public health system that allows countries to quickly detect and respond to disease outbreaks in their communities

What is International Health Regulations (IHR)? (cont.)

Countries are required to quickly notify

WHO of severe disease events that could

spread internationally, also referred to as

public health emergencies of international

concern.

This rapid notification allows WHO to quickly guide

a coordinated global response to such an event and

minimize unnecessary interference on travel or

trade.

IHR entered into force in June 2007.

Has the United States reported any major public health events in the last

few years?

Since June 2007, WHO has assessed and

posted 28 public health events from the

United States on a secure website

accessible by other WHO Member States,

including:

2009 influenza pandemic

other novel influenza

several outbreaks associated with contaminated

food items

What is a potential public health emergency of international concern?

A public health emergency of international concern is defined as an extraordinary event that may constitute a public health risk to other countries through international spread of disease and may require an international coordinated response.

Four decision criteria are used to assess public health events:

1. Is the public health impact of this event potentially serious?

2. Is this event unusual or unexpected?

3. Is there the potential for international spread?

4. Is there the potential for travel and trade restrictions?

If 2 of the 4 criteria are met, countries are required to notify WHO within 24 hours.

What is a potential public health emergency of international concern?

(cont.)

4 diseases always need to be reported to WHO: Severe acute respiratory syndrome or SARS

Smallpox

New influenza viruses

Wild-type polio

The Director-General of WHO determines if the event is a public health emergency of international concern.

The role of countries is to assess the magnitude and potential risk involved with an event, and WHO’s role is to make the decision.

What is a potential public health emergency of international concern?

(cont.)

With this design, WHO, as our global public

health authority, can quickly assess the global

risk of an event and, if needed, convene

countries to mount a coordinated

international response.

Countries don’t need to know what the cause

or the source of an outbreak is to report it to

WHO.

The focus is on early detection and reporting

to allow for a public health response before

international spread occurs, or at least

minimize the global impact of an outbreak.

What is a potential public health emergency of international concern?

(cont.)

An example of SARS:

The outbreak of SARS started in China in 2002.

Early on, we didn’t know that the illness was caused by a coronavirus or that it had likely jumped from animals to human.

The event met 2 of assessment criteria of a public health emergency of international concern:

• Serious impact of public health: the disease could kill people, but we didn’t know what it was, how it was transmitted, how we could prevent or treat it, and who could get sick from it.

• Potential for international spread: we knew that the disease affected travelers, who could ‘export’ the disease to other countries.

What is a potential public health emergency of international concern?

(cont.)

An example of SARS (cont.): This event would have been a prime event to report to WHO

under the IHR and to benefit from a coordinated international response.

If we had had the current IHR already in place during the SARS outbreak, it is possible that WHO would have learned sooner about the event.

• This could have enabled scientists to potentially identify the cause of this illness sooner.

• Some of the significant economic impact on China because of travel warnings by many countries against travel to China might have been prevented through modified global recommendations.

It is because of SARS that the global public health community got together to revise an older set of the international health regulations and adopt the current set.

What is about the IHR system?

All countries must designate a point of contact, called the National Focal Point, for communication to and from WHO at all times.

In the United States, the Secretary’s Operation Center at the Department of Health and Human Services serves as National Focal Point. The center notifies WHO of potential public health threats in

the United States that meet the assessment criteria in the IHR.

The assessment is largely conducted by senior scientists at CDC.

• CDC invites the relevant state epidemiologist and representatives from the Council of State and Territorial Epidemiologists to join the assessment.

• The assessment is performed within 48 hours of becoming aware of an event that could merit reporting to WHO.

• CDC becomes aware of an events through many different sources (e.g. routine disease notification systems, media reports, anecdotal reports by astute public health practitioners).

How successful has the IHR system been?

The system has been very successful when

we consider the number of events notified

to WHO under regulations.

>220 events worldwide were formally notified to

WHO and posted on the secure IHR website as

meeting at least 2 of the 4 risk assessment criteria.

Hundreds of more postings on a secure IHR website

for information exchange on events between

countries, which could include information about

event response measures taken.

How successful has the IHR system been? (cont.)

The system was put to the test during the 2009 influenza pandemic.

CDC reported the first 2 laboratory-confirmed cases of this novel flu strain to WHO in 2009.

After further consultation with the United States and Mexico, WHO determined within a few days that this event was indeed a public health emergency of international concern.

Seven weeks later, WHO declared this outbreak to be a pandemic.

Quickly, many other countries reported cases of pandemic influenza to WHO under the IHR framework.

WHO initiated regular in depth calls with all countries to better understand the global picture of this outbreak and to learn about best measures to minimize its impact.

As a result, WHO was able to make harmonized recommendations to all countries in an effort to minimize unnecessary control measures.

How successful has the IHR system been? (cont.)

The system also allows rapid information

exchange between two countries directly

through the National Focal Points.

Ex. In the United States, we are contacted regularly

through this system by other countries letting us know

about US citizens who were potentially exposed to an

infectious disease while traveling overseas.

This exchange of information allows us to contact those

citizens and offer public health follow-up and prevention

measures if indicated.

How successful has the IHR system been? (cont.)

This system establishes a standardized risk assessment tool that all countries have signed on to.

This tool greatly facilitates the assessment of events happening in more than one country at the same time.

• Ex. The United States and Mexico jointly assessed a cluster of acute flaccid paralysis with cases on both sides of the border on the basis of the IHR criteria and were able to do so quickly, not only because of pre-established relationships that we have with counterparts in Mexico and the United States, but also because we had a common pre-approved platform against which to judge the seriousness of the event.

Why was it necessary for WHO to revise its International Health Regulations

back in 2005? WHO revised the 1969 version of the IHR after

recognizing that more and more people rapidly travel from one part of the world to another and are more connected than ever through travel and trade.

To address this reality, WHO made 3 key changes to the IHR: Countries now need to report all events based on the 4 risk

assessment criteria, when previously, only 3 predefined diseases needed to be reported.

The IHR shifted from preventing the international spread of disease through control at the border to containment at the source.

The current IHR no longer lists a prescribed set of response measures, but these regulations allow countries to adapt measures to best address the event

These changes should allow the global public health community to react faster and more flexibly to public health events.

Is there still room for improving the assessment and reporting of public

health events to WHO?

While many countries have reported public

health events with the potential for international

spread since the IHR entered into force, not all

the countries have done so, and not all have

done so frequently or for all appropriate events.

The basis for assessment and reporting is to

have information to assess, but many countries:

have not yet reached the minimum core requirements

that allow them to detect outbreaks

have not yet had a solid public health system in place

for notifying others of such events within their own

country

Is there still room for improving the assessment and reporting of public

health events to WHO? (cont.) Assessment and notification is only one side of the coin,

while the other side is the ability to quickly and adequately respond to a disease threat in one’s country. This response capacity is another requirement not yet met by

many countries.

As we currently mark the 5-year milestone when countries are supposed to be fully implemented under the IHR, many countries have requested a 2-year extension to achieve the core requirements for surveillance and response.

WHO is working closely with countries to achieve this goal.

The United States is also assisting where possible (e.g. through training programs of international public health professionals, or by providing technical assistance in setting up systems for disease detection).

Are there strategies public health authorities can take to help people

become better informed about international public health

emergencies? Much of the information sharing under the IHR happens between different Ministries of Health and WHO.

People in the affected countries continue to rely on information shared in the media or by the responsible public health authorities directly.

In my experience, public health authorities can reap greater health benefits when they: quickly share pertinent information about an outbreak with the public make it a priority to communicate with the public about ways to

prevent and control the spread of disease

The IHR can assist with this by allowing all countries, including countries with limited resources to: become aware of what’s going on in other parts of the world learn what appropriate health prevention and control measures to

apply request assistance as needed

For more information, please contact:Emerging Infectious DiseasesCenters for Disease Control and Prevention1600 Clifton Road NE, Mailstop D61, Atlanta, GA 30333, USATelephone: 1-404-639-1960/Fax: 1-404-639-1954E-mail: eideditor@cdc.gov Web: http://www.cdc.gov/eid/

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Emerging and Zoonotic Infectious Diseases

Emerging Infectious Diseases

Thank you to all authorsKatrin S. Kohl, Ray R. Arthur, Ralph O’Connor, and Jose

Fernandez